ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Question 1 of 5
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: B,C,E
Rationale: Sensors (
B) alert caregivers to wandering, a mattress on the floor (
C) reduces fall injury, and high locks (E) prevent exits. A chair (
A) doesn’t address wandering and may harm, while bedtime activity (
D) may increase alertness, not sleep.
Question 2 of 5
A nurse is assessing a client who has post-traumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all that apply)
Correct Answer: A,D,E
Rationale: Clients with PTSD often exhibit persistent negative beliefs about self (
A), difficulty sleeping (
D), and trouble concentrating (E) due to hyperarousal and intrusive thoughts. Excessive talking (
B) and blaming others (
C) are not diagnostic criteria, with avoidance or withdrawal being more typical.
Question 3 of 5
A nurse is caring for a client who has a new diagnosis of metastatic lung cancer. The client states, 'I can't think about that until after my first grandchild is born next week.' The nurse should identify the client's statement as indicating the maladaptive use of which of the following defense mechanisms?
Correct Answer: A
Rationale: Suppression involves consciously avoiding distressing thoughts, as seen here, but delaying a terminal diagnosis indefinitely can be maladaptive, hindering treatment. Compensation, regression, and sublimation involve different mechanisms (overachieving, reverting, or redirecting impulses), not applicable here.
Question 4 of 5
A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Informing the client of their right to refuse respects autonomy and addresses anxiety by empowering choice. Encouragement may coerce, family consent is inappropriate unless incompetent, and another nurse’s review doesn’t override refusal.
Question 5 of 5
A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?
Correct Answer: A
Rationale: Demonstrating orientation to person, place, and time suggests cognitive stability, indicating the client may no longer pose a risk, allowing restraint removal. Refusal of medication or threats of self-harm suggest ongoing risk, and following commands alone isn’t sufficient without broader assessment.